11 years 7 months ago - 11 years 7 months ago#21895by Patricia
Jersey Girl..........this is a quote from a former medical insurance examiner...
If you are denied service then you need to appeal your request until they either approve your request or all appeals are exhausted. Depending on the state there is usually a multi level review process. In most cases the 1st request revivew is based on specific guidelines and is reviewed by a nurse or a non specialty matched MD. Often the second level is again by a different MD that is not specialty matched. By the 3rd request if the next step is not a specialty matched MD then you should request that the reviewing MD be specialty matched. Since we are all under a time constrait for getting things done in a set timeframe I would recommend that what ever level appeal you are at "BE SURE TO REQUEST THAT IT BE EXPEDITED". Make sure you appeal until there are no appeals left. In many cases I have found in doing reviews for other things that the problem is the request is not supported by the clinical submitted by the requesting MD. We would approve something if there was more information. We also have the ability to surf the internet and insurance company websites. Try to find anytype of documentationthat may help your case. We all have to be our own best advocate. Many things that were once deemed investagational & exoerimental are now routine procedures. That happened because enough people pushed to get things done to give insurance companies the data to prove the benefit.
Now i would submit data from Web/Cafe.......http://blcwebcafe.org/imagingstudies.asp
and heres one from U. of Virginia
I'm looking for more..they're out there.........be persistent.......Pat
Unfortunately, many insurance companies will not pay for a PET scan because it is a very expensive test. Definitely push for it if you can, it is a valuable tool in seeing if the cancer is present. If it wasn't for the PET scan, my father would never have known that his cancer had spread and we would be dealing with his treatment differently.
It enrages me as well that the insurance companies can control things the way that they do. I really will be praying for you that you get the results from this that you need!
Vent away! Insurance company's are hard to deal with if you don't have a map, and they don't hand out the map. I am so sorry that you lost your mom, the suddenness of it just makes it harder. You are in all of our thoughts and prayers. I hope the Uro can work around the insurance and help Jerry get the tests he needs.
On October 1st, Jerry had a routine CT scan (his second one since finishing chemo in Jan). On October 3rd the oncologist told us the scan showed a few nodes in his abdomen that were enlarged, with at least one, maybe two, being large enough to biopsy. So we were told to expect a call setting up the biopsy.
A week later we got a call that the hospital was saying they saw nothing that was large enough to biopsy. Our doctor was going to request a biopsy again (more strongly request). We were now almost 2 weeks post CT.
Friday morning, as we were gathering up to go into the church auditorium for my mom's funeral (can we say great timing???), our doctor's office called and said still no go on the biopsy, so they planned to push the insurance for a PET scan. We let our family know what was going on (as we were already gathered together).
Today, our doctor's office calls to tell us the insurance is refusing to approve a PET scan. ARGH!
So, the next suggestion they've offered is to fax all the stuff to Jerry's urologist who did his neobladder surgery. We already had an appointment set up for Wednesday afternoon. They think maybe this doctor could biopsy.
I guess I am just not understanding how insurance can refuse a test that would allow Jerry to immediately begin treatment if his cancer has indeed returned. We know it was in 7 of the 24 nodes removed in the original neo surgery, so there is a good chance these enlarged nodes are connected. We are now almost 3 weeks post CT...seems like time is flying by while "suits" somewhere who are NOT doctors decide something that could make the difference between life and not....ARGH!!!!
Not to mention another ride on the emotional roller coaster....I am wiped out...exactly 21 days ago right now, I had no idea that my mom was sick, much less that she would pass away...and I had no idea that Jerry was possibly in jeopardy, too...
Thanks for letting me vent...you guys are awesome...and what keeps me going some days...